Christina Worley - Module 2

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Arizona State University *

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501

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Health Science

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Apr 3, 2024

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Module 2 – Compliance Oversight Agencies OIG One of the largest federal government agencies responsible for oversight of hospital organizations is the Department of Health and Human Services Office of Inspector General (OIG). The OIG creates compliance resources for healthcare providers and physicians to assist with Federal laws and regulations. Some of the compliance documents provided to healthcare organizations and providers are fraud alerts, advisory bulletins, podcasts, videos, and brochures “providing guidance on compliance with Federal health care program standards” (U.S. Department of Health and Human Services, n.d.). Additionally, the Office of Audit Services within the OIG conducts audits on HHS programs and help to eliminate fraud, waste, and abuse (U.S. Department of Health, n.d.). There are some very important laws that the OIG, as well as the Department of Justice and the Centers for Medicare & Medicaid Services (CMS) are responsible for enforcing. The False Claims Act states that “it is illegal to submit claims for payment to Medicare or Medicaid that you know or should know are false or fraudulent” (U.S. Department of Health & Human Services, pg. 4, n.d.). The Anti-Kickback Statute “prohibits the knowing and willful payment of remuneration to induce or reward patient referrals or the generation of business involving any item or service payable by the Federal health care programs” (U.S. Department of Health & Human Services, pg. 5, n.d.). The Physician Self-Referral Law also knows as the Stark Law, “prohibits physicians from referring patients to receive designated health services payable by Medicare & Medicaid from entities with which the physician or an immediate family member has financial relationship” (U.S. Department of Health & Human Services, pg. 7, n.d.). Lastly, the OIG is responsible for excluding from participation in all Federal health care programs any

individuals or entities that have criminal offenses involving Medicare or Medicaid fraud, patient abuse or neglect, felony convictions related to controlled substances, or felony convictions for health-care related fraud (U.S. Department of Health & Human Services, n.d.). If a physician or healthcare organization is excluded by the OIG, they are prohibited from billing for services provided to Medicare and Medicaid beneficiaries. The OIG does publish enforcement actions on their website. One action that was recently posted on their website involved Alton Memorial Hospital having to pay $147,000 for violating the Civil Monetary Penalties Law for employing an excluded individual (OIG, 2023). The OIG website also posts the List of Excluded Individuals/Entities (LELI). This list contains every person or entity that has been excluded from participation in federally funded programs. The OIG recommends that healthcare organizations routinely check this list to ensure that new hires or current employees are not on the list; otherwise, they could be subject to civil monetary penalties (CMP) (U.S. Department of Health & Human Services, n.d.). Another important part of the OIG is the Work Plan, which “sets forth various projects including OIG audits and evaluations that are underway or planned to be addressed during the fiscal year and beyond by the OIG’s Office of Audit Services and Office of Evaluation and Inspections” (U.S. Department of Health and Human Services, para. 2, n.d.). Maryland Medicaid Fraud Control Unit Another government agency responsible for oversight of hospital organizations is the state Medicaid Fraud Control Units. The hospital organization that I have chosen is in the state of Maryland, so the Maryland Medicaid Fraud Control Unit would be responsible for prosecuting Medicaid fraud and the abuse and neglect of vulnerable adults. Fraud is prosecuted by the

Maryland Medicaid Fraud Control Unit in two ways: prosecution of healthcare providers who steal from the Medicaid program and secondly, fraud in the administration of the program (Maryland Office of the Attorney General, n.d.). The Maryland Medicaid Fraud Control Unit does not list any enforcement actions or trends on their website. There is a form to report health care fraud and another form to report abuse and neglect of vulnerable adults. The Office for Civil Rights The Office for Civil Rights is a federal agency that has oversight of hospital organizations. One of the largest areas that the Office for Civil Rights manages is the Privacy and Security Rule under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The Office for Civil Rights handles HIPAA breach notifications. Hospitals are required to report to the Office for Civile Rights when there has been a breach of unsecured protected health information. Depending on the number of individuals affected by the breach, the OCR requires healthcare providers to provide individual notifications, media notifications, and a notification to the Secretary of the Office of Civil Rights. Lastly, the OCR is responsible for the enforcement of process when a breach notification occurs, which means a healthcare organization could be fined heavily by the OCR for breaches of unsecured protected health information (U.S. Department of Health and Human Services, 2020). The OCR does publish their enforcement actions on their website. For example, in recent news, UnitedHealthcare was required to pay an $80,000 settlement to HHS to resolve a matter over a patient medical record request. The incident occurred in March 2021, when the OCR was notified that UHC did not respond timely to a medical record request. The patient requested their

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